Resuscitation under 32 weeks: thermal bundles, FiO₂ 30%, and CPAP from breath one

Preterm neonates born before 32 weeks present unique physiological challenges in the delivery room. Their gelatinous skin lacks a mature stratum corneum, creating rapid evaporative heat loss. Their highly compliant rib cage collapses inward against non-compliant, surfactant-deficient lungs. Furthermore, their cerebral germinal matrix vessels are vulnerable to intraventricular hemorrhage during sudden blood pressure swings.

The NRP 9th Edition outlines a distinct stabilization protocol designed specifically for very and extremely preterm infants. Here is the step-by-step clinical approach.

The thermal protection bundle

Hypothermia upon admission to the NICU directly increases neonatal mortality, metabolic acidosis, and late-onset sepsis. For infants born under 32 weeks, conventional towel drying and radiant heat alone are insufficient to prevent rapid core cooling.

Polyethylene wrap or bag: As soon as the infant is delivered, place them directly into a clean polyethylene plastic bag or wrap from the feet up to the neck without towel drying. Leaving the amniotic fluid on the skin inside the sealed barrier creates a humidified microclimate that eliminates evaporative heat loss.

Chemical thermal mattress: Activate a portable exothermic warming mattress and place it beneath the radiant warmer blankets before delivery.

Head covering: Place a warm knit or lined hat on the head. The large surface area of the neonatal cranium accounts for over 20% of total convective heat loss.

Axillary temperature monitoring: Attach a skin temperature servo probe to the right upper abdomen, aiming for a target body temperature of 36.5°C to 37.5°C.

Starting FiO₂ and oxygen titration

While term infants begin resuscitation in 21% room air, infants born before 32 weeks require moderate supplemental oxygen to overcome high pulmonary vascular resistance and surfactant deficiency.

Connect a compressed air/oxygen blender and set the initial FiO₂ to 30% or higher (30% to 35%). Place the pulse oximeter sensor on the right wrist and titrate oxygen in steady 10% to 15% increments to match the standard preductal SpO₂ target table:

Ventilation: CPAP first, gentle PEEP always

Historically, extremely preterm infants were routinely intubated in the delivery room for prophylactic surfactant. Large randomized clinical trials have since demonstrated that routine intubation and mechanical ventilation cause acute barotrauma and increase bronchopulmonary dysplasia (BPD).

Early Delivery Room CPAP: If the infant breathes spontaneously and has a heart rate of 100 bpm or higher, immediately apply CPAP at 5 cm H₂O using a T-piece resuscitator with an anatomic mask or short bi-nasal prongs. CPAP establishes functional residual capacity, prevents alveolar collapse at end-expiration, and decreases work of breathing.

If Positive-Pressure Ventilation (PPV) is needed: If the infant is apneic, gasping, or bradycardic (<100 bpm), begin PPV using a T-piece resuscitator. The T-piece provides a consistent PEEP of 5 cm H₂O and an initial peak inspiratory pressure (PIP) of 20 to 25 cm H₂O, protecting fragile lung units from atelectrauma.

Surfactant administration strategy

If an infant on CPAP develops severe respiratory distress, increasing oxygen requirements (FiO₂ > 30%), or requires intubation for ineffective breathing, administer surfactant promptly.

Surfactant can be instilled via an endotracheal tube (with brief ventilation or immediate extubation to CPAP) or through minimally invasive surfactant therapy (MIST / LISA) using a thin vascular catheter while the baby remains on noninvasive CPAP.